STANDARD OPERATING PROCEDURES

STANDARD OPERATING PROCEDURES

Contents

Introduction.......................................................................................................................2

Patient Demographics........................................................................................................3

Address Details...........................................................................................................3

Surgical admission.......................................................................................................3

ID Numbers.................................................................................................................3

Linked data..................................................................................................................4

Patient follow-up........................................................................................................4

Study data...................................................................................................................4

Pre-Operative Data............................................................................................................5

Surgical Admission....................................................................................................11

Operative Data ................................................................................................................12

Operative findings.....................................................................................................12

Post-operative destination.......................................................................................13

Recovery Data..................................................................................................................14

Post-Operative visit on Day 2 or 3....................................................................................15

Post-Operative visit on day 7............................................................................................16

On death or discharge from hospital................................................................................19

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INTRODUCTION

The Perioperative Quality Improvement Programme (PQIP) was set up in 2016 by the National Institute of Academic Anaesthesia and the Health Services Research Centre working on behalf of the Royal College of Anaesthetists. Our aim is to improve the outcomes of patients undergoing major non-cardiac surgery. PQIP will measure complications, risk-adjusted mortality and patient reported outcomes on a random sample of five cases per week so we can try to reduce complication rates, improve patient experience and quality of life after surgery.

We have constructed a dataset which we would like you to complete for each patient participating in this study. As there can be many interpretations of questions we have provided this document, a standard operating procedure (SOP) for the PQIP dataset, to provide guidance on correct completion of the form.

Please note that this SOP refers only to the questions that are to be completed by the clinicians or researchers and not by patients themselves.

As you complete the questions in the web-tool, the menu bar will change colour to highlight your progress: blue for empty or unsaved sections; red for sections with errors; orange for incomplete sections requiring further data entry; green for fully completed sections.

If you have any questions please contact the PQIP team at pqip@rcoa.ac.uk

Thank you for your support.

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PATIENT DEMOGRAPHICS

1.1 Enter the patient’s local hospital ID number.

1.2 Enter the patient’s surname.

1.3 Enter the patient’s first name as registered on the hospital system.

1.4 Enter the patient’s date of birth in the format ‘DD/MM/YYYY’.

1.5 Select the patient’s current gender.

ADDRESS DETAILS

1.6 Enter the patient’s current postcode – enter the outward code (1st part) in the first box and the inward code (2nd part) in the second box.

1.7 Select one of the two options that best describes the patient’s usual residence: Own home – private residence either owned or rented. This would include sheltered

accommodation. Care home – residential or nursing home where assisted living is provided.

SURGICAL ADMISSION

1.8 Enter the patient’s date of admission to hospital for this procedure in the format ‘DD/MM/YYYY’.

1.9 Enter the patient’s date of surgery in the format ‘DD/MM/YYYY’.

1.10 The patient’s age at the time of surgery will be automatically filled in by the web-tool.

ID NUMBERS

1.11 – For Scottish hospitals, enter the patient’s CHI number. For hospitals in the rest of 1.12 the U.K. enter the patient’s NHS number.

1.13 Enter the patient’s height in centimetres (cm). 1.14 Enter the patient’s weight in kilograms (kg).

1.15 – The patient’s body surface area, body mass index and ideal body weight will be 1.17 calculated automatically by the web-tool.

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LINKED DATA

1.18 – Linked data on mortality and re-admission will be automatically filled in by the web1.19 tool as these data become available.

PATIENT FOLLOW-UP

1.20 Enter how the patient would like to be contacted in 6 and 12 months’ time to complete the follow-up questionnaire. This should be indicated on the completed consent form.

STUDY DATA

1.21 Enter if the patient is enrolled in any other studies. If yes, please note the study.

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PRE-OPERATIVE DATA

2.1 & Select the surgical specialty and planned procedure from the lists provided. The 2.2 specialties and procedures to be included are:

All major Head and Neck resections including:

Craniofacial resection (+/- reconstruction)

Extensive excision of mandible (+/- reconstruction)

Glossectomy (total)

Laryngectomy (partial)

Laryngectomy (subtotal)

Laryngectomy (total)

Laryngotracheal reconstruction following PLO

Mediastinal thyroidectomy/parathyroidectomy with sternotomy

VATS excision of mediastinal tumour (including thymectomy)

Partial excision of trachea and reconstruction

Pharyngectomy (partial)

Pharyngectomy (total)

Pharyngolaryngo-oesophagectomy (PLO)

Radical dissection of cervical lymph nodes

Radical dissection of cervical lymph nodes with local myocutaneous flap reconstruction

Radical dissection of cervical lymph nodes with distant myocutaneous flap reconstruction

Selective dissection of cervical lymph nodes

Selective dissection of cervical lymph nodes with local myocutaneous flap reconstruction

Selective dissection of cervical lymph nodes with distant myocutaneous flap reconstruction

Thoracics:

VATS bullectomy (unilateral)

VATS bullectomy (bilateral)

VATS excision of mediastinal tumour (including thymectomy)

VATS lobectomy

VATS lung volume reduction (unilateral/bilateral)

VATS pleurodesis/pleurectomy

VATS wedge resection of lung

Carinal resection with pneumonectomy

Carinal resection (without pneumonectomy)

Decortication of pleura of the lung

Excision of chest wall tumour (+/- reconstruction)

Lung resection with excision of chest wall

Open excision of lesion of lung

Open resection of mediastinal tumour

Partial excision of trachea and reconstruction

Pulmonary lobectomy including segmental resection

Thoracotomy and closure of bronchopleural fistula

Thoracotomy and bullectomy (unilateral)

Thoracotomy and bullectomy (bilateral)

Thoracotomy and lung volume reduction

Thoracotomy and pleurectomy/pleurodesis (+/- ligation of bullae)

Abdominal - Hepatobiliary:

Hemihepatectomy (left)

Hemihepatectomy (right)

Partial hepatectomy (+/- ablation)

Pancreatectomy (partial/distal)

Pancreatectomy (total)

Abdominal - Upper GI:

Partial gastrectomy (+/- excision of surrounding tissue)

Total gastrectomy (+/- excision of surrounding tissue)

Bypass of oesophagus

Oesophagectomy (partial)

Oesophagectomy (total)/Oesophagogastrectomy

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Pancreaticoduodenectomy (Whipple procedure)

Radiofrequency thermocoagulation of the liver with scapel resection

Resection of lesion(s) of liver

Splenectomy (partial/total)

Exploratory laparotomy

Pancreatectomy (partial/distal)

Pancreatectomy (total)

Pancreaticoduodenectomy (Whipple procedure)

Splenectomy (partial/total)

Intestinal failure reconstruction

Laparotomy + restoration of intestinal continuity

Laparotomy for enterocutaneous fistula

Exploratory laparotomy

Restoration of intestinal continuity

Resection of duodenal tumour

Resection of small bowel tumour

Complex restoration of intestinal continuity

Partial excision of bile duct and anastamosis of bile duct to duodenum/jejunum

Abdominal - Lower GI:

Abdominal revision of restorative proctocolectomy

Abdominoperineal (AP) resection with anastamosis (+/- pouch)

Abdominoperineal (AP) resection with end colostomy

Anterior resection

Colectomy and colostomy with preservation of rectum

Colectomy (total) and ileorectal anastamosis

Excision of retroperitoneal tumour (+/- ureterolysis)

Hartmann's procedure

Left hemicolectomy (with anastamosis)

Left hemicolectomy (with colostomy)

Panproctocolectomy and ileostomy

Right hemicolectomy (with anastamosis)

Right hemicolectomy (with ileostomy)

Abdominoperineal pull-though resection with colo-anal anastomosis +/- colonic pouch and associated stoma

Intestinal failure reconstruction

Laparotomy + restoration of intestinal continuity

Laparotomy for enterocutaneous fistula

Reversal of Hartmann's procedure

Completion proctectomy

Restoration of intestinal continuity

Exploratory laparotomy

Sigmoid colectomy

Complex restoration of intestinal continuity

Urology

Total cystectomy (with construction of intestinal conduit or neo-bladder)

Abdominal - other:

Abdominal wall reconstruction

Adrenalectomy (unilateral)

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Retroperitoneal lymph node dissection

Total nephrectomy (non-transplant)

Radical prostatectomy

Pelvic exenteration

Adrenalectomy (biilateral)

Excision of retroperitoneal tumour (+/- ureterolysis)

Laparotomy + excision of sarcoma tumour

Retroperitoneal lymph node dissection

Exploratory laparotomy

Pelvic exenteration

The magnitude of surgery will be automatically generated from the choices made in questions 2.1 – 2.2. Surgical magnitude is determined using the AXA-PPP schedule of procedures and is the same as that used in the Surgical Outcome Risk Tool (SORT) (www.sortsurgery.com).

2.2b Please select all that apply to the mode of surgery for this operation.

2.3 PQIP is currently only collecting data on patients having planned surgery. Choose from the following:

Expedited – Patient requiring early treatment where the condition is not an immediate threat to life, limb or organ survival. Normally within days of decision to operate. This might include urgent cancer surgery for example.

Elective – Intervention planned or booked in advance of routine admission to hospital. Timing to suit patient, hospital and staff.

2.4 Select if the patient is on an enhanced recovery pathway. This includes any protocolised pathway aimed at improving patient outcome and reducing length of stay.

2.5 Select one or more options from the list which best describe the form of preoperative assessment undertaken prior to hospital admission. Free text available if other chosen.

2.6 Enter the patient’s most recent serum sodium prior to surgery in mmol/L.

2.7 Enter the patient’s most recent serum potassium prior to surgery in mmol/L (to one decimal place).

2.8 Enter the patient’s most recent serum urea prior to surgery in mmol/L (to one decimal place).

2.9 Enter the patient’s most recent serum creatinine prior to surgery in μmol/L.

2.10 Enter the patient’s most recent serum albumin prior to surgery in g/L.

2.11 Enter the patient’s most recent white cell count prior to surgery in x109/L (to one decimal place).

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2.12 Enter the patient’s most recent haemoglobin prior to surgery in g/dL (to one decimal place).

2.13 Enter the patient’s pulse rate in beats per minute (bpm).

2.14 Enter the patient’s systolic blood pressure in mmHg.

2.15 Enter the patient’s Glasgow Coma Scale total (from 3 – 15):

Eye opening Best verbal response Best motor response

SpontaneousTo soundTo pressureNone

4321

OrientatedConfusedWordsSoundsNone

54321

Obeys commandsLocalises painNormal flexion to painAbnormal flexion to painExtension to painNone

654321

2.16 Enter the patient’s oxygen saturations (%) measured in the supine position and after resting for one minute. If the patient is on supplemental oxygen please remove for 10 minutes and then measure oxygen saturations at rest.

2.17 Select one option that best describes the patient’s pre-operative ECG.

2.18 Select one option that best describes the patient’s current cardiac history/findings.

2.19 Select one option that best describes the patient’s current heart failure status according to the NYHA classification:

I - No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnoea

II - Slight limitation of physical activity. Comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnoea

III - Marked limitation of physical activity. Comfortable at rest. Less than ordinary activity causes fatigue, palpitation, or dyspnoea

IV - Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.

2.20 Select one option that best describes the patient’s current respiratory history/findings.

2.21 Select if the patient has had an acute upper or lower respiratory tract infection in the month prior to surgery.

2.22 Select one option provided as to the patient’s history of cerebrovascular disease: No. Yes – no hemiplegia: history of TIA or stroke with no or minor sequelae. Yes – with hemiplegia: stroke with hemiplegia.

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2.23 Select one or more of the cancer diagnosis options that are current or have been in remission for less than five years:

No. Yes – solid tumour: local only (exclude if > 5 years from diagnosis). Yes – solid tumour: metastatic disease (including lymph node). Yes – Lymphoma (NHL, Hodgkin's, Waldenström, multiple myeloma). Yes – Leukaemia (acute or chronic).

2.24 Select if the patient has a chronic cognitive deficit (dementia is defined as per ICD-10).

2.25 Select if the patient has diabetes mellitus. If on oral medication and insulin- enter as on insulin. End organ damage includes retinopathy, neuropathy and nephropathy. If the patient is type 2 diabetic please select the option of how the diabetes is controlled.

2.26 Enter the patient’s most recent HbA1c prior to surgery as a % (to one decimal place) if they are being treated for diabetes mellitus. A conversion calculator from mmol/mol or mmol/L can be accessed through the webtool.

2.27 Select one of the options if the patient has liver disease. Cirrhosis can either be diagnosed radiologically, histologically or grossly.

2.28 Grade the patient’s risk according to the American Society of Anesthesiologists physical status (ASA-PS) classification:

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2.29 Select if the patient has had preoperative cardiopulmonary exercise testing. If so, enter the results, if available, in the form provided (entering CPET data is optional).

2.30 Select one option which best describes the patient’s smoking history. Smoking includes all forms of inhaled tobacco (but not electronic cigarettes or other nicotine delivery systems, e.g. chewing gum).

2.31 Select if the patient was referred to a smoking cessation service, regardless of attendance. (This question only appears if “current smoker” chosen on question 2.31)

2.32 Select one option which best describes the patient’s current daily alcohol consumption. One alcohol unit equals 10ml or 8g of pure alcohol which equals one 25ml single measure of whiskey (ABV 40%), or a third of a pint of beer (ABV 5-6%), or half a standard (175ml) glass of red wine (ABV12%).

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ASA grade

Definition Further explanation

ASA I A normal healthy patient

Healthy, non-smoking, no or minimal alcohol use

ASA II A patient with mild systemic disease

Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (30 < BMI < 40), well-controlled DM/HTN, mild lung disease

ASA III A patient with severe systemic disease

Substantive functional limitations: one or more moderate to severe diseases. Examples include (but not limited to): poorly controlled DM or HTN, COPD, morbid obesity (BMI ≥40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, ESRD undergoing regularly scheduled dialysis, premature infant PCA < 60 weeks, history (>3 months) of MI, CVA, TIA, or CAD/stents.

ASA IV A patient with severe systemic disease that is a constant threat to life

Examples include (but not limited to): recent (< 3 months) MI, CVA, TIA, or CAD/stents, ongoing cardiac ischemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis

ASA V A moribund patient who is not expected to survive without the operation

Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intracranial bleed with mass effect, ischemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction

ASA VI A declared brain-dead patient whose organs are being removed for donor purposes

2.33 Select the type of perioperative risk assessment, if any, that was recorded in the notes or consent form. All forms of risk stratification accepted.

2.34 Select the patient’s planned post-operative destination. Level 0 (ward) – Patients whose needs can be met through normal ward care in an acute hospital. Level 1 – Patients at risk of their condition deteriorating, or those recently relocated from higher

levels of care, whose needs can be met on an acute ward with additional advice and support from the critical care team.

Level 2 – Patients requiring more detailed observation or intervention including support for a single failing organ system or post-operative care and those ‘stepping down’ from higher levels of care.

Level 3 – Patients requiring advanced respiratory support alone or basic respiratory support together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure.

SURGICAL ADMISSION

2.35 Select if the patient received oral mechanical bowel preparation.

2.36 Select if the patient received a clear carbohydrate drink approximately 2 hours prior to surgery.

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OPERATIVE DATA

3.1 Select the grade of the most senior surgeon that was physically present in the operating theatre.

3.2 Select the grade of the most senior anaesthetist that was physically present in the operating theatre.

3.3 Select if appropriate prophylactic antibiotics were given within 60 minutes of skin incision. “Appropriate antibiotic prophylaxis” is compliance with local protocols. If no antibiotics are required according to local protocols and none were given, this constitutes appropriate antibiotic prophylaxis.

3.4 Select the type of anaesthesia that the patient received and then the form(s) of intraoperative analgesia they received (i.e. intravenous analgesia, local infiltration, regional block or neuroaxial block).

3.5 Select any additional intraoperative monitoring that the patient had in addition to the standard monitoring for all operations.

Standard AAGBI monitoring includes: pulse oximeter, non-invasive blood pressure, electrocardiograph, airway pressure and airway gases (oxygen, carbon dioxide, anaesthetic agent)

Cardiac output monitoring includes any device that was inserted or used to assess the fluid responsiveness of the patient during the surgical procedure. It includes Oesophageal Doppler, Pleth Variability Index (PVI), echocardiogram, arterial pulse contour analysis, pulmonary artery catheter, partial non-rebreathing systems, thoracic bio impedance, endotracheal cardiac output monitor.

3.6 Select type of warming device, if any, was used on the patient. Select all options that apply.

OPERATIVE FINDINGS

3.7 Including the present procedure, select the number of operations the patient has had in the previous 30 days.

3.8- Select if the actual procedure was the same as the overall planned procedure. If 3.10 different, select the actual procedure performed from the lists available. Refer to sections

2.1 – 2.3. For question 3.9b, please select all that apply (for example if the operation proceeded from laparoscopic assisted to open, please tick both)

3.11 Select which surgical incision was performed. If more than one incision, please choose the higher ranking incision: intra-thoracic > upper abdominal > lower abdominal > other/laparoscopic.

3.12 Select the range of estimated total blood loss for the procedure.

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3.13 In cases where the abdominal cavity was entered, select the option which best describes the degree of peritoneal soiling.

3.14 Select the length of time that the patient was under general anaesthesia for the procedure.

POST-OPERATIVE DESTINATION

3.15 Select the patient’s actual postoperative destination.

3.16 If the actual destination is different from that planned (see question 2.36) please select the reason why. Choose from the options listed or type in the free text box.

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RECOVERY DATA

If the patient is transferred directly to a higher-level care facility postoperatively then the “recovery period” should be regarded as the immediate three hours postoperatively.

4.1 Select yes if the first core temperature taken in recovery is greater than or equal to 36C.

4.2 Select yes if an abdominal drain is present on arrival from theatre.

4.3 Select yes if a nasogastric tube is present on arrival from theatre.

4.4 Select the patient’s highest recorded pain score during their stay in recovery.We would suggest converting numerical pain scales as follows:

0-3 scale: 0 = None; 1 = Mild, 2 = Moderate, 3 = Severe 0-10 scale: 0 = None,1-3 = Mild; 4-6 = Moderate; 7-10 = Severe

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POST-OPERATIVE VISIT ON DAY 2 OR 3

Answer these questions with regard to the patient’s status on post-operative day 1.

5.1 Select yes if IV maintenance fluids were discontinued within 24 hours after completion of surgery.

5.2 Select yes if the patient was tolerating free fluids within 24 hours after completion of surgery. This should be at least 1.5-2.5 litres daily.

5.3 Select yes if the patient restarted oral diet (at least soft diet e.g. yoghurt, porridge, fruit) within 24 hours of completion of surgery and tolerated it. This does not have to be full normal diet.

5.4 Select yes if the patient mobilized from bed to chair with maximum assistance of one person within 24 hours of completion of surgery.

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POST-OPERATIVE VISIT ON DAY 7

6.1 – Select yes if the patient is currently in hospital on day 7. If yes, select the patient’s 6.2 current location from the options listed.

The following questions form the Post-Operative Morbidity Survey (POMS), an 18-item survey addressing nine domains of postoperative morbidity. In answering them you should consider the patient’s status on day 7 post-operatively.

6.3 Pulmonary – Select all options that apply. If the patient has been receiving long-term oxygen therapy and has recovered back to their

original level of oxygen requirement prior to surgery, please select “None of the above”. If the patient is receiving any advanced respiratory (including non-invasive ventilation or

high flow nasal cannula) support that was not present before surgery, please select “New requirement for ventilator”.

6.4 Infectious – Select all options that apply. Select if the patient is on IV antibiotics – this does not include oral antibiotics. Select if the patient has had a temperature of 38C or greater during the 24 hours preceding the time point at which the day 7 data is being collected.

6.5 Gastrointestinal – Select all options that apply. Select “Unable to tolerate enteral nutrition” if:

receiving TPN nil by mouth clear fluids only free fluids only soft diet only NG tube on free drainage or high NG aspirates NG fed but not tolerating full prescribed amount and therefore needs to remain in hospital

Select “Nausea, vomiting or abdominal distention” if the patient is unable to return to their previous normal diet for the above reasons, this includes paralytic ileus and patients who are requiring anti-emetics.

Select “None of the above” if the patient is unable to eat their full normal diet because their appetite has not fully returned.

6.6 Renal – Select all options that apply. Select “Oliguria” if the urine output was less than 500ml during the 24 hours preceding the time point at which the day 7 data is being collected. Do not select this option if the urine output is greater than or equal to 500ml in the preceding 24 hours, if the urine output is not recorded or the fluid balance is inexact.

Select “Creatinine 30% greater than pre-operative level” if the serum creatinine during the 24 hours preceding the time-point at which the day 7 data is being collected is 30% greater than the pre-operative value. This should not be selected if less than 30% increase

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or if not measured in the preceding 24 hours. Use the pre-operative creatinine value closest to the date of surgery as the baseline value.

Select “Urinary catheter in-situ” if the patient has a urethral or supra-pubic catheter in-situ that was not present prior to surgery.

6.7 Cardiovascular – Select all options that apply. Select “Hypotension” if, during the 24 hours preceding the time point at which the day 7 data is being collected, the patient has required >200ml of fluid resuscitation or has required a mini-jet or infusion of adrenaline or noradrenaline. This does not include GTN infusion for pulmonary oedema.

Select “New myocardial infarction or ischaemia” if, during the 24 hours preceding the time point at which the day 7 data is being collected, the patient has had a serum troponin sample taken, an ECG, echocardiogram, thrombolysis, a stent, PCI or if they require GTN spray or infusion for chest pain or ischaemic changes. This does not include routine post-operative ECGs.

Select “Thrombotic event requiring anticoagulation” if, at present or during the 24 hours preceding the time point at which the day 7 data is being collected, the patient required warfarin, heparin, treatment-dose low molecular weight heparin, or other anticoagulation. This does not include prophylactic anticoagulation, return to treatment dose anticoagulation if the patient was on anticoagulation prior to hospital admission, clopidogrel or aspirin.

Select “Arrhythmias” if, during the 24 hours preceding the time point at which the day 7 data is being collected, the ECG shows any dysrhythmia or if the patient had a non-routine ECG (unless this is for diagnosis of MI in which case “New myocardial infarction or ischemia” should be selected).

Select “Cardiogenic pulmonary oedema” if at present or during the 24 hrs preceding the time point at which the 7 day data is being collected, the patient has been started on GTN or furosemide for pulmonary oedema.

6.8 Neurological – Select all options that apply. Select “New neurological deficit” if, at present or during the 24 hours preceding the time point at which the day 7 data is being collected, the patient has a new focal neurological deficit that was not present pre-operatively.

Select “Delirium or confusion” if, at present or during the 24 hours preceding the time point at which the day 7 data is being collected, the patient’s family or nursing staff report the patient’s behavior is not normal (new confusion or delirium that was not present pre-operatively, or if the patient has pre-existing confusion or delirium that is worse compared to their pre operative state).

Select “Sedative-induced coma” if the patient is in a sedative-induced coma.

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6.9 Wound – Select all options that apply. Select if the patient has required surgical exploration of a dehisced surgical wound, drainage of pus from the operation wound, oozing from the surgical wound, if a swab is sent to a laboratory or if a VAC drain is in situ.

6.10 Haematological – Select all options that apply. Select “Red cell transfusion” if the patient has received a red blood cell transfusion during the 24 hours preceding the time point at which the day 7 data is being collected.

Select “Fresh frozen plasma/cryoprecipitate/platelets” if any were given at any point during the 24 hours preceding the time point at which the day 7 data is being collected.

6.11 Pain – Select all options that apply. Select if the patient has received parenteral opioids or regional anaesthesia during the 24 hours preceding the time point at which the day 7 data is being collected. This includes PCA, epidural, IV or IM pain relief. This does not include oral analgesia or using transdermal patches.

6.12 Select yes if the patient has returned to their baseline level of mobility during the 24 hours preceding the time point at which the day 7 data is being collected.

6.13 Select all the reasons that explain why the patient still requires admission on day 7 post-operatively.

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ON DEATH OR DISCHARGE FROM HOSPITAL

7.1 Enter the date of discharge, death or withdrawal in the format ‘DD/MM/YYYY’

Select the discharge destination or if patient has died prior to discharge or withdrawal from study.

7.2 Select the grade of complication experienced by the patient during their primary admission for surgery. If the patient experienced multiple complications please list each relevant level of complication.

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